Provider Demographics
NPI:1851911135
Name:MIRMOTAHARI, MIRIAM ELIZABETH (NP)
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:ELIZABETH
Last Name:MIRMOTAHARI
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11262 CAMPUS ST
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92350-1727
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15030 7TH ST
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-3811
Practice Address - Country:US
Practice Address - Phone:833-438-8763
Practice Address - Fax:833-438-8700
Is Sole Proprietor?:No
Enumeration Date:2020-04-16
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA95019163363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program